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ACA resources nurses need to help patients make the right choices

Friday October 11, 2013
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As open enrollment for health insurance under the
Affordable Care Act rolls out, the country’s top nurse administrator is calling on nurses to help their uninsured patients get coverage.

“Nurses are in a natural role to do this,” said Marilyn Tavenner, RN, BSN, MHA, administrator for the Centers for Medicare & Medicaid Services. “They are seen as trusted individuals. They understand the importance of individuals and families having health insurance, getting preventive care to prevent a health problem before it impacts quality of life, not to mention the associated costs, and they’re seen as true patient advocates. Nurses just generally understand the
importance of having health insurance.” Open enrollment for coverage starting Jan. 1 officially began Oct. 1, although some states have delayed it a couple of weeks. Throughout the process, nurses will encounter questions about the new law in all healthcare settings, from hospital rooms to home care, as well as in nursing schools and their communities, Tavenner said.

“It hasn’t seemed real up until now,” she said. “But now it’s a matter of people getting up to speed.”

Regardless of their personal feelings about the law, nurses will want to make sure their patients get the right information, said Diana Mason, RN, PhD, FAAN, nursing professor and co-director of the Center for Health, Media, & Policy at Hunter College, City University of New York. “I believe every nurse has a moral duty to make sure people know they can get health insurance at an affordable cost,” Mason said. Those who want to do more to help their patients and fellow community members get covered have a number of options, from working with employers to training as navigators to sitting on state insurance exchange boards.

“Funny, when you don’t talk about the politics, but you talk to people about trying to get healthcare, the politics kind of takes care of itself,” Tavenner said.

4 levels of nurse involvement

Level 1: Basic information and referral for patients. Busy nurses don’t need to be insurance experts, but when patients have questions about health coverage or worry about how to pay for care, all nurses should be able to refer them to someone in the facility or community who can help them apply for health insurance if they want it, and let them make their own decisions. At a minimum, nurses can explain to patients that they can sign up for an insurance plan any time between Oct. 1 and March 31 for coverage starting in 2014; that they may face a penalty if they don’t get health insurance; and that the insurance is not free, but they may qualify for subsidies to help with premiums or for Medicaid (which they usually do not have to pay for). Nurses also can refer patients to HealthCare.gov, the insurance hotline at 800-318-2596 or the sources listed below for information.

Level 2: Working with colleagues, Nurses who want to be more active in helping patients get health insurance can ask their employers what the organization has available to educate patients and staff and offer their skills as educators to help organize classes for staff, if necessary. A number of large health organizations have received grants to train people to give unbiased information to patients and community members about getting health insurance. The California Hospital Association has published a manual for hospitals in the state to help staff enroll uninsured patients in health plans such as CalHospital.org. Many hospitals and community health centers have signed up to become certified enrollment entities to help people apply for coverage. If employers don’t have a resource person to help patients with insurance questions, nurses can suggest designating someone to do that job or at least posting basic information and referral websites and phone numbers where patients can see them. Faculty in schools of nursing can work with student health departments to help educate students, who may not be insured or who may be graduating and losing their school-based insurance.

Level 3: Working in the community. Nurses can spread the word in their churches, community centers, schools and community organizations such as Parent Teacher Associations. As health experts and trusted members of society, nurses can explain the new law to those who may benefit from it and let them know where to go for information. They can help community groups become certified enrollment entities that will help people apply for coverage.

They can seek out and work with trained community educators or become navigators at certified enrollment agencies, non-navigator assistance personnel or certified application counselors themselves. State exchange (insurance marketplace) websites offer places to sign up for training, and the Centers for Medicare & Medicaid Services has a list of organizations that have received grants to offer navigator training. Training is ongoing, and the government also will offer refresher courses.

Level 4: Working for policy change. Healthcare reform is constantly evolving, and nursing should be involved in the changes. Nurses can sit on state insurance exchange boards, be part of state campaigns to promote Medicaid expansion and advocate for advanced practice nurses to be included as primary care providers in state and federal exchanges. They also can be involved through their professional organizations. The American Nurses Association has a campaign to make sure nurse practitioners are included as providers in state exchanges: NursingWorld.org/EspeciallyForYou/AdvancedPracticeNurses/APRN-News/APRN-Inclusion-in-Insurance-Exchanges.html. Nurses in Arizona are working with their state organization to support Medicaid expansion there: AZNurse.org.

(Sources: Marilyn Tavenner, RN, BSN, MHA; Diana Mason, RN, PhD, FAAN; American Nurses Association; California Hospital Association; and Arizona Nurses Association)

The basics of health insurance exchanges

Health insurance exchanges — also called marketplaces — offer four levels of insurance coverage. Bronze: Patient pays the lowest premium, but about 40% of out-of-pocket healthcare costs through copays and deductibles; Silver: Patient pays about 30% of costs; Gold: Patient pays about 20% of costs; Platinum: Patient pays the highest premium and about 10% of costs.

All insurance plans must offer the following essential health benefits. No one may be denied health insurance because of a pre-existing condition.

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

People under 30 and those with very low incomes who cannot get other types of insurance may choose a catastrophic plan. These cost less than the other plans, but require patients to pay all health costs except for preventive services up to a certain amount, usually several thousand dollars, after which the insurance company usually will cover the 10 basic services. Subsidies may not be applied toward catastrophic plans.

People without insurance can sign up for a plan any time between Oct. 1 and March 31 to be covered in 2014. Coverage starts Jan 1 for those who sign up by Dec. 15.

Twenty-two states and the District of Columbia have chosen to expand their Medicaid programs, which means those making up to 138% of poverty level (about $33,000 for a family of four) will be eligible. Those in other states who are not eligible for subsidies are exempt from fines for not having health insurance.

In all states, people making up to about $45,000 ($94,000 for a family of four) may qualify for subsidies to help pay for insurance. Currently 16 states and the District of Columbia are operating their own exchanges, seven have created exchanges in partnership with the federal government and the rest are letting the federal government run the exchange.

Both state and federal websites will list participating insurance companies and have an application process available. People without access to the Internet can apply by phone or in person at a certified enrollment entity, such as a hospital or community center.

Penalties for not buying insurance are $95 per adult, $47.50 per child, and $285 or 1% of household income for uninsured families in 2014. By 2016, this will increase to $695 per adult, $347.50 per child and $925 or 2.5% of income for families.

(Sources: HealthCare.gov, American Nurses Association, Kaiser Family Foundation, WebMD)

Helpful websites

Centers for Medicare & Medicaid Services: Nurses and other healthcare professionals who want to help patients, friends or relatives through the process of getting healthcare on state or federal exchanges can visit Marketplace.CMS.gov for a variety of materials and information designed for their use. At the home site, click on “Publications and Articles” to get fact sheets, wallet-sized resource cards and other handouts.

The federal government: The top source for information about the ACA’s mandatory health insurance provision, including eligibility and how to enroll in an insurance exchange plan, is HealthCare.gov. The website also will direct people to state websites for signing up for Medicaid and insurance on state-run exchanges. (Those who don’t have access to a computer can call 800-318-2596.)

Kaiser Family Foundation: KFF has been following healthcare reform since 2010, when it first rolled out. The website (KFF.org/Health-Reform) features a calculator that provides a rough estimate of what people will pay annually for health insurance, based on income, age and family size. Other features include a quiz to help separate myth and fact; a timeline showing which reforms have already happened and which are still to come; a state-by-state tool to show potential changes in Medicaid enrollment; and a variety of news updates, polls and opinion pieces.

WebMD: Secretary of Health and Human Services Kathleen Sebelius praised this website (WebMD.com/Health-Insurance/Health-Check-Health-Insurance/default.htm), which has an extensive and easy-to-follow explanation of health insurance reform, including Q&As, a monthly cost calculator, quizzes and links to state sites.

AARP: Two websites from the AARP have reliable information about the ACA insurance exchanges. Health Law Answers (HealthLawAnswers.AARP.org) has a step-by-step tool to see what type of coverage might be best for people, given their age, income level and state of residence. Health Law Facts (AARP.org/health/affordable-care-act) offers information about preventive care and Medicare benefits, a list of resources and an extensive glossary.

Enroll America: This nonpartisan organization, which includes health insurers, hospitals, consumer groups, faith-based organizations, clinicians and others, is working to enroll uninsured Americans in coverage made available by the ACA. Its website (EnrollAmerica.org) offers tips for providers to talk to patients, best practices for enrollment and information on navigator and other in-person assistance programs.

Glossary of terms

Affordable Care Act: The comprehensive healthcare reform law enacted in March 2010, intended to make healthcare in America more accessible and affordable. One of its most important provisions — which goes into effect Jan. 1, — is to require everyone to have health insurance, with tax breaks to help people at certain income levels pay for coverage.

Grandfathered health plan: A group health plan created — or an individual health insurance policy purchased — on or before March 23, 2010. Grandfathered plans are exempted from many ACA-required changes. Plans or policies may lose their grandfathered status if they make certain significant changes that reduce benefits or increase costs to consumers.

Health Insurance Marketplace (also called health insurance exchange): The official federal name for a place where individuals, families and small businesses can learn about health coverage options, compare insurance plans, choose a plan and enroll in coverage. In some states it is run by the state, in others by the federal government, and in a handful it’s a partnership between the two. The marketplace also provides information to help people with low to moderate income pay for coverage, including information about other programs such as Medicaid and the Children’s Health Insurance Program. The marketplace encourages competition among private health plans and is accessible through websites, call centers and in-person assistance.

Navigator: An individual or organization trained to help consumers and small businesses look for health coverage options through the exchanges, including completing eligibility and enrollment forms. Navigators are required to be unbiased, and their services are free to consumers. Others who can help people get covered are certified applicant counselors (affiliated with a designated organization) and application assistors.

Open enrollment: The period of time during which people can enroll in a qualified health plan through a health exchange. For 2014, open enrollment is Oct. 1, 2013 to March 31, 2014. For 2015 and later years, it is Oct. 15 to Dec. 7 of the previous year. People also may qualify for special enrollment periods outside of open enrollment if they experience certain events, such as moving to a new state or changes in income or family size. Applications for health coverage outside of the exchanges, Medicaid or CHIP are accepted any time of the year.

Premium tax credit (also called advance premium tax credit): A new tax credit, based on income, to help pay for health insurance purchased through a federal- or state-run exchange. Advance credits can be used right away to lower monthly premiums. Those who qualify choose how much of the credit to apply to premiums each month. Anything left over is refunded when tax returns are filed. If advance payments are more than the amount of the credit, the excess must be repaid at tax time.

Qualified health plan: An insurance plan certified by the Health Insurance Marketplace (federal and state health exchanges) that provides essential health benefits, follows established limits on cost-sharing (such as deductibles, copayments and out-of-pocket maximum amounts), and meets other requirements.

(For a full list, visit: Healthcare.gov/Glossary)

The ACA so far

Since March, 2010 when it was signed into law, the Affordable Care Act has brought these changes to American healthcare:

• Coverage for children with pre-existing conditions.
• Allowing children to remain on their parents’ health insurance until age 26.
• No more lifetime limits on coverage.
• Prescription drug discounts for seniors.
• Free preventive care, including well-woman visits, for people with health insurance and seniors on Medicare.
• The requirement that insurance companies spend at least 80% of their premium charges on medical care and efforts to improve the quality of care.

Myths & facts

Myth: There is one government-sponsored plan in which people will be enrolled.
Fact: Insurance will be offered by a mix of for-profit and not-for-profit companies. Medicaid, which is government-sponsored insurance, will be expanded in some states to cover those making up to 138% of poverty level ($33,000 annually for a family of four).

Myth: Medicare premiums will go up.
Fact: Medicare will not be affected by the insurance mandate requirement of the ACA. Medicare recipients are getting free preventive services and drug discounts under the ACA.

Myth: If a person has insurance, it will go away next year.
Fact: If a person already has employer-sponsored or individual insurance, it will probably not change any more than usual — most of these plans will be grandfathered in. A few people may lose their current individual coverage because some insurers who are not participating in the exchanges are pulling out of the individual market. Some employers have reported dropping insurance for part-time workers and spouses.

Myth: Insurance will be free.
Fact: Individual insurance plans will cost money. But many of those currently uninsured will either be eligible to have the entire cost covered by Medicaid or receive subsidies to buy insurance from an exchange. Some people will pay the entire cost themselves, but will be able to choose from a variety of price ranges and plans.

Myth: Health choices will be restricted.
Fact: Most previously uninsured people’s health choices will be considerably expanded. Because healthcare is expensive, uninsured people have few options other than EDs or clinics serving low-income residents. The ACA allows uninsured people to get insurance through Medicaid or buy it on an exchange, which should give them greater access to a variety of healthcare providers and services, including preventive care.

Myth: Premiums will go up on individual insurance plans.
Fact: Those with pre-existing conditions, women and older people are more likely to see their premiums decrease. Copays and deductibles also may decrease, and limits on how much insurance companies will pay for care will be eliminated.

Myth: Premiums will go down under the new law.
Fact: For a healthy young person who has a low-cost, high-deductible individual policy, the premiums are more likely to increase. But coverage will probably be better. And those who make less than $45,000 are probably eligible for subsidies.

Myth: People who don’t buy health insurance will go to jail.
Fact: The only penalty for not buying insurance will be fines assessed through federal tax returns.

(Sources: HealthCare.gov, Kaiser Family Foundation, AARP)

Continuing coverage

For continuing coverage of ACA news and information through implementation, regularly visit Nurse.com/ACA.


Cathryn Domrose is a staff writer.